Healthcare Provider Details

I. General information

NPI: 1417031923
Provider Name (Legal Business Name): PENNSYLVANIA CENTER FOR DENTAL IMPLANTS AND PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9880 BUSTLETON AVE #211-212
PHILADELPHIA PA
19115-2185
US

IV. Provider business mailing address

9880 BUSTLETON AVE #211-212
PHILADELPHIA PA
19115-2185
US

V. Phone/Fax

Practice location:
  • Phone: 215-677-8686
  • Fax: 215-677-7212
Mailing address:
  • Phone: 215-677-8686
  • Fax: 215-677-7212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS022257L
License Number StatePA

VIII. Authorized Official

Name: DR. ROBERT A LEVINE
Title or Position: OWNER
Credential: DDS,PC
Phone: 215-677-8686